1 FRAUD THE UNINSURABLE RISK 2 FRAUD THE UNINSURABLE RISK o The Workers' Compensation Fraud Program was established in 1991. The legislature made workers' compensation fraud a felony, required insurers to report suspected fraud, and established a mechanism for funding enforcement and prosecution activities. The legislation established the Fraud Assessment Commission to determine the level of assessments to fund investigation and prosecution of workers compensation insurance fraud. o

Funding for the program comes from California employers who are legally required to be insured or self-insured. 3 CALIFORNIA FUNDING FOR SIU For the 2015-2016 Fiscal Californians were awarded 34.9 million in grants to assist law enforcement in fighting workers compensation fraud. County FY 2015/16 Workers' Compensation Insurance Fraud Grant Funding Alameda $1,511,933 Amador $386,479 Butte $76,000 Contra Costa

$850,000 El Dorado $271,428 Fresno $1,236,000 Humboldt $200,000 Imperial $163,495 Kern $1,058,000 Kings $263,875 Los Angeles Marin Merced $6,458,643 $245,648

$174,000 4 Monterey Napa Nevada Orange Placer Riverside Sacramento San Bernardino San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa

Barbara Santa Clara Santa Cruz Shasta Siskiyou Solano Sonoma Tehama Tulare Ventura Yolo TOTAL $660,000 $135,500 $73,525 $3,966,000 $175,000 $2,020,000 $910,000

$2,113,943 $4,990,459 $713,943 $472,972 $54,419 $691,588 $340,420 $2,626,811 $118,223 $154,955 $52,992 $175,742 $66,800 $110,248 $499,258 $683,465 $250,067 $34,951,831 5

FRAUD IN THE WORK PLACE o Terms o Definitions o Provisions o Legislation o

Fraud o Red Flags o SIU o CA Insurance Code4 1877.3. 1871.4 o Authorized Governmental Agency 6

WHAT IS WORKERS' COMP CLAIMS FRAUD? The Claims Fraud Statue: : o Insurance Code 1871.4 o Simply stated: When someone knowingly lies to obtain some benefit or advantage, or cause some benefit that is due to be denied. o Penal Code 550 (b) (3) o

Concealing or knowingly failing to disclose the occurrence of an event that affects a persons benefits whether that be entitlement, amount or duration may constitute workers compensation fraud. = difference to the determination of benefits. 7 PREMIUM FRAUD Premium Fraud Statutes o Insurance Code 11760 o Insurance Code 11880 o Simply Stated: When someone knowingly lies to obtain a W/C

policy of Insurance at less than the proper rate, cost or premium. 8 WHO CAN COMMENT FRAUD? o Employees o Employers o Providers ( i.e. Doctors, Chiropractors, Voc. Rehab. Counselors, copy Services Pharmacys, Interpreters, etc.,) o

Attorneys o Insurance Company Employees o Brokers and Agents o Anyone who touches the Insurance Industry 9 TYPES OF INSURANCE FRAUD o Premium /Policy

o Health care Fraud o Property and Casualty Fraud o Auto Insurance Fraud o Employer Claims Fraud o Workers Compensation Fraud

o Broker/Agent o Provider Fraud o Claimant/Applicant ( Auto, Property and Casualty ,workers compensation, Medi-care/ Medi -Cal All Lines of Insurance have been victimized ) o Attorney Fraud o Insurance Company Employee Fraud

10 SUSPECTED FRAUD REPORTING IS LEGALLY MANDATED .. o Required by Insurance Code 1877.3 o Who has the duty to report: Insurers admitted to transact Insurance in California. State Compensation Insurance Fund Self-insured employers Third party administrators Licensed rating organizations. 11 SUSPECTED FRAUD REPORTING 1. Must report when you know or reasonably believe you know the identiity of a person or entity who you have reason to belief committed a fraudulent act relating to Insurance.

2. Must use prescribed forms ( FDI) - Called Suspected Fraudulent Claims Report (SFC) 3. Must state on the notice the basis of the suspected fraud. 4. Report Filing date not to exceed 30 days from day on which the duty to report arose. 12 LIMITED CIVIL IMMUNITY FOR REPORTING Insurance Code 1877.5 Insurer reports to Authorized Governmental Agencies In Good Faith Without Malice Have Reasonable Belief Warranted by known facts Obtained by reasonable Efforts 13

SPECIAL INVESTIGATION UNIT 14 DUTIES OF CLAIMS EXAMINERS In 1994 California State Rules and Regulations mandated all Insurance Carriers to formulate a Special Investigation Unit.. Many Insurance companies promoted and trained Claims Examiners in The Art of detecting, investigating and management of fraudulent claims. What is the Role of the SIU Investigator? To conduct further research into the suspected fraudulent claim. If the matter if found to be potentially fraudulent, then the facts and misrepresentations are documented. The Facts supporting the suspicion or allegation of fraud are referred to the proper authorities. 15 HOW IS AN INVESTIGATION STARTED?

Each SIU Investigator must answer two main questions: 1. Is this situation of potential fraud or a case of abuse? 2. If the claim is potentially fraudulent, can it be proven? To prove fraud, four elements of fraud have to be established. Definition of Abuse A. Abuse is any practice that uses the Insurance system in a way that is contrary to either the intended purpose of the system or law. Abuse includes some behavior that is criminal and some that is not. Criminal abuse is call fraud. Typical Abuses of the system include: 1. Magnification of complaints or disability that falls short of an outright lie. 2. Overutilization of benefits and services 16 HOW IS AN INVESTIGATION STARTED? 3. An Employer failing to advise its insurance carrier that additional classifications have been added to the business for coverage purposes. 4. Filing a claim that may not be compensable.

5. Violating the rules of the Insurance system. 6. Making a mistake on an estimate of future payroll. The examples listed above may be wrong and constitute abuse but his behavior may not rise to the level of criminal fraud. It can be dealt with in other ways: Through claims handling, underwriting, or the Workers compensation Appeals Board. Also, evaluating whether or not a workers compensation claim is compensable is not the test to determine whether the claim is fraudulent. Specific Elements of fraud must be present. 17 18 WHAT ARE THE ELEMENTS OF FRAUD? Definition of Fraud B. Fraud occurs when someone knowingly lies to obtain some benefit or advantage to which they are not otherwise entitled, or to deny some benefits that is due and to which someone is entitled, or to obtain a insurance policy at less than the proper rate, cost or premium.

C. Elements of Fraud: 1. There is always a false representation THE LIE 2. The LIE must be knowingly made. perjury) ( Depositions help prove of penalty of 3. The LIE must be made for the intent of obtaining a benefit that is not due, denying a benefit that is due or obtaining insurance at less that the proper rate, premium, or cost. 4. The LIE must be material. In other words, the LIE must make a difference. Ask the Question, if the truth had been told, would anything have been done differently? 19 LETS INVESTIGATE 20

21 22

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